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w <br /> r <br /> VAU E L L IP U IPV1 F F E RPV �u <br /> t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East:Hazelton Avenue-STOCICTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CAI_? 20 Uj3-7G97 FOR INSPECTIONS EXPIRES I YEAR FROM DAT E ISSUED <br /> -70 2 Ln <br /> JOB ADDRESS k). SG,'AA44 ti7 V SI _ CITYIZIP S7vcicre✓ e4ff,rZo Z m <br /> o <br /> (,• �L USS STn—CI N1PN 3 PARCELSIZE ~�d LAND USEAPPLICATION# � M <br /> CROSS STREET m <br /> in <br /> OWNER I`1AMEL�1-S:�T �- PQA.lf -7,t (30b 143'qPFIONE G <br /> OWNER.DDRESS GD C.( G A LIQ UIQ s77 CITYISTATE/7-IP S 70Gk L'* 64Z017- <br /> CONTRACTOR [/ Lei D n � C <br /> --TIG.Ii�Gyp PHONE y Z -7�-T. JyUo <br /> �j <br /> CONTRACTOR ADDRESS !�O H 0 W E A0 O�l CIT YISTATE/IIP e4 '9 I. T-r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/QIP ct <br /> LICENSE -57 ❑ C-6'I ❑ D-09 ❑ Other NUMBER �ULlt4 EXPIRATION DATE ! - <br /> GEOGRAPHICAL INFORMATION: Coordinates X y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone NumDer <br /> TYPE Oiz UUoRK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modif icalion ❑ Other <br /> ❑ Monitoring Wells rp of wells ❑ Soil Boring(s)u It of borings #k of borings <br /> Monitoring O g(�) if-Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection RepairA L�pT-Y4-A/&C• 1, <br /> ❑ New Pump ❑ Pump Replacement ❑ PLimp Repair ❑ Raise Well Casing ` , <br /> WELL CONSTRUCTION /1 P- - O <br /> Drilling i'tlethod ❑ Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth /o a ft Excavation in diameter ❑ Open Bottom ❑ Gravel PacldGravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth foe ft ¢,Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ther T/lZ6NS� ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller D Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thicic in ❑ Christy Bou ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other- HP Pump Set ft `Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT,I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> UMC HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ./ <br /> SIGNED TITLE Se.ySO-1 DATE <br /> ----- — ---- — -- — — — <br /> IIRRRR <br /> M N <br /> — --- — HEA TV DEW <br /> NT <br /> DE A\RTMENT U E NLY <br /> Application Accepted By ` Date Area Employee ID#- <br /> Grout Inspection By Date Ql'l e l Permit <br /> Pump Inspection By Date_ WAIVER Received <br /> Soil Boringlft <br /> nspection By yfl�w(" Lt/�� DatF- [ / 1�— Constructed Well Depth <br /> � <br /> COMMENTS / ! <br /> PE SC Received Amount Date Permit/ Invoice Well il)tk <br /> Codes Info BY A Cash Remitted Service Request; <br /> WP 0o 5a <br /> EFID 43.00 WELL/PUMP PERMIT <br /> 8104/08 <br />